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Note: Statistics may vary from previous years due to revised and updated source statistics or addition of new data sources.

In 1999, the IOM published To Err Is Human, which called for a national effort to reduce medical errors and increase patient safety.74 The IOM defines patient safety as freedom from accidental injury due to medical care or medical errors.74 In response to the IOM's report on patient safety, the President signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) to spur the development of voluntary, provider-driven initiatives to improve the quality, safety, and outcomes of patient care. The act addresses many of the current barriers to improving patient care.

Measuring patient safety is complicated by difficulties assessing and ensuring the systematic reporting of medical errors and patient safety events. All too often, patient safety event reporting systems are laborious and cumbersome. Health care providers may also fear that if they participate in the analysis of medical errors or patient care processes, the findings may be used against them in court or harm their professional reputations. Many factors limit the ability to aggregate data in sufficient numbers to rapidly identify prevalent risks and hazards in the delivery of patient care, their underlying causes, and practices that are most effective in mitigating them. These include difficulties aggregating and sharing data confidentially across facilities or State lines.

To Err Is Human does not mention race or ethnicity when discussing the problem of patient safety. A 2006 review of the literature found that only 9 of 323 articles on pediatric patient safety (2.8%) included race or ethnicity in the analysis. Five of the nine studies from this review used data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.82

This section highlights 10 measures of patient safety in three areas:

Surgical complications.

Other complications of hospital care.

Complications of medications.

For findings related to all core measures of patient safety, go to Table 2.2a.

Surgical Complications

Adverse health events can occur during episodes of care, especially during and right after surgery. Although some surgical complications may be related to a patient's underlying condition, many can be avoided if adequate care is provided.

Postoperative Complications

Patients are vulnerable to a variety of complications soon after they undergo surgery. Complications may include, but are not limited to, pneumonia, urinary tract infection, and blood clots.

Note: Postoperative care complications included in this composite are postoperative pneumonia and venous thromboembolic event (blood clot). Note that this composite measure changed from 2004 to 2005, with the alteration of the complications of urinary tract infections being changed to catheter-associated urinary tract infections. Catheter-associated urinary tract infections was removed from this composite for 2006 data. Sensitivity analysis carried out on the composite shows that this change does not significantly alter the composite estimate. Data were unavailable for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

There were no statistically significant differences between Blacks and Whites in the percentage of hospital surgical patients with postoperative care complications (Figure 2.35).

Postoperative wound infections.

Infections acquired during hospital stays (nosocomial infections) are among the most serious safety concerns. A common hospital-acquired infection is a wound infection following surgery. Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right antibiotics at the right time on the day of their surgery. However, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects, such as stomachaches, serious types of diarrhea, and antibiotic resistance. Among adult hospital patients having surgery, the NHDR tracks a composite of two measures: receipt of antibiotics within 1 hour prior to surgical incision and discontinuation of antibiotics within 24 hours after end of surgery.

Note: Whites, Blacks, Asians, and AI/ANs are non-Hispanic groups. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders. Appropriate timing of antibiotics received by adult surgical patients for all payers included in this composite are: (1) antibiotics started within 1 hour of surgery, and (2) antibiotics stopped within 24 hours after surgery.

The percentage of appropriately timed antibiotics provided to surgery patients was significantly lower for Asians (78.0%) and Hispanics (74.7%) than for Whites (80.7%; Figure 2.36). There were no statistically significant differences for other groups.

Postoperative Wound Separation

Possible complications of abdominal and pelvic surgery include wound separation or rupture, involving all layers of the abdominal wall and the need for surgical reclosure. This can occur within 30 days of the procedure, typically between days 5 and 8. Separation is more likely to occur if wound infection is present and can lead to prolonged hospitalization and death.

Note: White, Black, and API are non-Hispanic Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Note: Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

There were no statistically significant differences between Whites and any racial or ethnic groups.

There were also no statistically significant differences between high-income and other income groups.

Accidental Puncture or Laceration

Adverse events are possible during any surgery or procedure, including the nicking or cutting of bodily organs and blood vessels. This may be especially true in emergent situations, when, according to an expert panel review, some of these occurrences are not preventable. Puncture or laceration can lead to serious complications.

Figure 2.39. Accidental puncture or laceration during procedure per 1,000 discharges, adults age 18 and over, by race/ethnicity, 2001-2005.

Note: White, Black, and API are non-Hispanic Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Figure 2.40. Accidental puncture or laceration during procedure per 1,000 discharges, adults age 18 and over, by income, 2005.

Note: Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Overall, from 2001 to 2005, the rate of accidental puncture or laceration during a procedure increased (Figure 2.39). The rate increased for all racial and ethnic groups except non-Hispanic Whites.

In 2005, the percentage of discharges of adults with accidental puncture or laceration during procedure was higher for APIs (4.9 per 1,000) than for non-Hispanic Whites (4.4 per 1,000).

There were no statistically significant differences by income in the rate of accidental puncture or laceration (Figure 2.40).

Other Complications of Hospital Care

Types of care delivered in hospitals in addition to surgery can place patients at risk for injury or death.

Adverse Events Associated With Central Venous Catheters

Patients who require a central venous catheter to be inserted into the great vessels of their heart tend to be severely ill. However, the procedure itself can result in a number of infectious and noninfectious complications.

Note: Central venous catheter complications included in this composite are bloodstream infections and mechanical adverse events. Data were not available for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

No statistically significant disparities were observed between Blacks and Whites in the percentage of central venous catheter complications among hospital patients (Figure 2.41).

Iatrogenic Pneumothorax

Iatrogenic pneumothorax is a partial or complete collapse of a lung, due to an accumulation of air in the pleural space (between the lungs and the chest wall) caused by medical care. This condition can be life threatening. This indicator is intended to track cases of pneumothorax caused by medical care.

Note: White, Black, and API are non-Hispanic Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Note: Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

From 2001 to 2005, the overall rate of iatrogenic pneumothorax decreased (Figure 2.42). The rate decreased for all groups except for Hispanics and Asians and Pacific Islanders. There were no statistically significant changes for income groups (data not shown).

From 2001 to 2005, the gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage of hospital discharges for adults with iatrogenic pneumothorax remained lower for Hispanics than for non-Hispanic Whites (0.55 per 1,000 compared with 0.71 per 1,000).

There were no other statistically significant differences by race or income (Figure 2.43).

Deaths Following Complications of Care

Many complications that arise during hospital stays cannot be prevented. However, rapid identification and aggressive treatment of complications may prevent these complications from leading to death. This indicator, also called "failure to rescue," tracks deaths among patients whose hospitalizations are complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer.

Denominator: Patients ages 18-74 from U.S. community hospitals whose hospitalization is complicated by pneumonia, thromboembolic event, sepsis, acute renal failure, shock, cardiac arrest, gastrointestinal bleeding, or acute ulcer. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Note: White, Black, and API are non-Hispanic Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

From 2001 to 2005, there was significant improvement overall in the rates of in-hospital deaths following complications of care (from 152.2 per 1,000 in 2001 to 125.8 per 1,000 in 2005; Figure 2.44).

During this period, the gap between Blacks and non-Hispanic Whites in the rates of in-hospital deaths following complications of care decreased. In 2005, there was no statistically significant difference between Blacks and non-Hispanic Whites.

The gap between Hispanics and non-Hispanic Whites stayed the same. In 2005, Hispanics had a higher rate of in-hospital deaths following complications of care than non-Hispanic Whites (131.0 per 1,000 compared with 125.2 per 1,000).

In 2005, there was no statistically significant difference between people living in communities with median household incomes of less than $25,000 and people living in communities with median household incomes of greater than $45,000 in the rate of deaths following complications of care (data not shown).

Deaths in Low Mortality Diagnosis Related Groups

Health care errors are more likely responsible for in-hospital deaths of patients admitted for low-risk illnesses or procedures than for deaths of high-risk patients.

Note: White, Black, and API are non-Hispanic Data are adjusted for age, gender, and DRG clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

Note: Data are adjusted for age, gender, and DRG clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 63% of the U.S. resident population.

From 2001 to 2005, there were no statistically significant changes in the rate of deaths in low-mortality diagnosis-related groups (DRGs) (Figure 2.45).

In 2005, the rate of deaths in low-mortality DRGs was lower for Hispanics than for non-Hispanic Whites (0.29 per 1,000 compared with 0.63 per 1,000).

While APIs have consistently had a lower rate of deaths in low-mortality DRGs, these were not significantly different from Whites.

There were no other statistically significant differences by race or income (Figure 2.46).

Complications of Medications

Complications of medications are common safety problems. Some adverse drug events may be related to misuse of medication, but others are not. However, prescribing medications that are inappropriate for a specific population may increase the risk of adverse drug events.

Adverse Drug Events in the Hospital

Some medications used in hospitals can cause serious complications. The Medicare Patient Safety Monitoring System tracks a number of "high-risk" drugs and the adverse events associated with them. Adverse drug events can include serious bleeding associated with intravenous heparin, subcutaneously administered low-molecular-weight heparin, and oral warfarin, as well as hypoglycemia associated with insulin or oral hypoglycemics.

Note: Data were not collected for Asians, Native Hawaiians and Other Pacific Islanders, American Indians and Alaska Natives, and Hispanics.

In 2006, between 5.2% and 15.5% of hospitalized Medicare patients overall experienced an adverse drug event in the hospital, depending on the type of drug (Figure 2.47).

From 2004 to 2006, there was no change in the percentage of patients taking intravenous heparin who experienced an adverse drug event. There was also no statistically significant difference between Blacks and Whites.

From 2004 to 2006, the percentage of patients taking low-molecular-weight heparin who experienced an adverse drug event decreased for all groups. However, Blacks were still more likely than Whites to have an adverse event (6.3% compared with 5.2%).

From 2004 to 2006, the percentage of patients taking warfarin who experienced an adverse drug event decreased overall except for Blacks. Blacks were more likely to experience an adverse drug event than Whites (9.0% compared with 5.9%).

From 2004 to 2006, the percentage of patients taking insulin or hypoglycemics who experienced an adverse drug event increased. There was no statistically significant difference between Blacks and Whites.

Potentially Inappropriate Medication Prescriptions for Older Patients

Some drugs that are appropriate for some patients are considered potentially harmful for older patients but are still prescribed to them.83,xx Inappropriate medication use by older patients includes drugs that should often be avoided for these patients.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives. This measure includes 33 inappropriate prescription medications. Prescription medications received include all prescribed medications initially purchased or otherwise obtained, as well as any refills.

In 2005, older Asians were more likely than older Whites to have inappropriate drug use (20.3% compared with 17.3%; Figure 2.48).

Older Hispanics were less likely than older non-Hispanic Whites to have inappropriate drug use (13.5% compared with 17.6%).

Older women were more likely than older men to have inappropriate drug use (20.2% compared with 14.3%).

There were no statistically significant differences by income or education.

Timeliness

Timeliness is the health care system's capacity to provide care quickly after a need is recognized. For patients, lack of timeliness can result in emotional distress, physical harm, and financial consequences.84,85 For example, stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy.86,87 Timely delivery of appropriate care can also help reduce mortality and morbidity for chronic conditions such as chronic kidney disease,88 and timely antibiotic treatments are associated with improved clinical outcomes.89 Timely delivery of childhood immunizations helps maximize protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks.90

Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries.91 Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient.92 Timely outpatient care can reduce admissions for pediatric asthma, which account for $1.25 billion in total hospitalization charges annually.93 The measures of timeliness highlighted in this section are getting care for illness or injury as soon as wanted and emergency department visits in which patients left without being seen. (For findings related to all core measures of timeliness, Tables 2.3a and 2.3b.)

Getting Care for Illness or Injury As Soon As Wanted

The ability of patients to receive illness and injury care in a timely fashion is a key element in a patient centered health care system.

Figure 2.49. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race (top left), ethnicity (top right), and income (bottom left), 2002-2005.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for American Indians and Alaska Natives

From 2002 to 2005, the gap between Blacks and Whites in the percentage of adults who reported sometimes or never getting care for illness or injury as soon as wanted remained the same (Figure 2.49). In 2005, Blacks fared worse than Whites on this measure of timeliness (20.9% compared with 13.4%).

From 2002 to 2005, the gap between Asians and Whites also remained the same. In 2005, Asians were twice as likely as Whites to report problems getting care as soon as wanted (27.4% compared with 13.4%).

During this period, the gap between Hispanics and non-Hispanic Whites in the percentage of adults who reported delayed care decreased. However, in 2005, Hispanics remained more likely than non-Hispanic Whites to report problems getting care as soon as wanted (17.7% compared with 12.8%).

During this period, the gap between poor and high-income people remained the same on this measure. In 2005, poor adults were about 2� times as likely as high-income adults to report problems getting care as soon as wanted (24.8% compared with 10.0%).

Racial and ethnic minorities are disproportionately of lower SES. To distinguish the effects of race, ethnicity, income, and education on timeliness of primary care, this measure is stratified by income and education level.

Figure 2.50. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race (left) and ethnicity (right), stratified by income, 2005.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

Figure 2.51. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race (left) and ethnicity (right), stratified by education, 2005.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

SES explains some but not all of the ethnic differences in timeliness of primary care (Figure 2.50 and Figure 2.51).

After stratification by income, high-income Hispanics were still more than twice as likely as high-income non-Hispanic Whites to report problems getting care as soon as wanted (18.1% compared with 8.6%).

After stratification by education, Blacks with a high school education and at least some college education were still almost twice as likely as Whites of the same education level to report problems getting care as soon as wanted (21.1% compared with 11.5% for high school graduates, and 19.3% compared with 11.8% for people with at least some college education).

After stratification by education, among people with some college, Hispanics were almost twice as likely as non-Hispanic Whites to report problems getting care as soon as wanted (19.5% compared with 11.2%).

Figure 2.52. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by race (top left), ethnicity (top right), and income (bottom left), 2002-2005.

Reference population: Civilian noninstitutionalized population under age 18.

From 2002 to 2005, there were no statistically significant changes in the percentage of children whose parents reported problems getting care as soon as wanted (Figure 2.52).

There were no statistically significant differences observed between Blacks and Whites, between Hispanics and non-Hispanic Whites, and between poor and high-income children.

Emergency Department Visits in Which Patients Left Without Being Seen

In 2004, patients who had an emergency department (ED) visit in the United States spent an average of 3.3 hours in the ED, with 47 minutes spent waiting to be seen by a physician.94 This may reflect the 18% increase in ED visit volumes over the past 10 years, as the number of ED facilities has decreased by 12.4%.94 There are many reasons that a patient seeking care in an ED may leave without being seen, but long waits tend to explain many departures.

Figure 2.53. Emergency department (ED) visits in which patients left without being seen, by race (left) and payment source (right), 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.

Denominator: Visits by patients (of all ages) to the EDs of non-Federal, short-stay, and general hospitals, exclusive of military and Department of Veterans Affairs hospitals.

Note: Data were insufficient for this analysis for Asians, Native Hawaiians and Other Pacific Islanders, and American Indians and Alaska Natives.

Between 1997-1998 and 2005-2006, the overall percentage of ED visits in which the patient left without being seen almost doubled, from 1.2% to 2.0% (Figure 2.53).

During this period, the gap between Blacks and Whites increased. In 2005-2006, Blacks were more likely to leave without being seen than Whites (2.9% compared with 1.8%).

During this period, the percentage of ED visits in which Medicaid patients left without being seen remained the same and was higher than it was among patients with private insurance (in 2005-2006, 1.9% compared with 1.6%).

During this period, the gap between uninsured patients and patients with private insurance remained the same. Uninsured patients were about twice as likely to leave without being seen as patients with private insurance (3.1% compared with 1.6%).

Medicare patients were the least likely to leave the ED without being seen.